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For further information, see CMDT Part 24-10: Intracranial & Spinal Mass Lesions

Key Features

  • Most common sources of intracranial metastasis

    • Lung cancer

    • Breast cancer

    • Skin cancer (melanoma)

    • Kidney cancer

    • GI tract cancer

  • 10–15% of brain metastases are of unknown primary source

  • Most common metastatic carcinomas to the leptomeninges are breast, lung, lymphomas, and leukemia

Clinical Findings

  • Intracranial metastases and primary cerebral neoplasms present similarly

    • Intracranial pressure

    • Focal or diffuse disturbance of cerebral function

  • Leptomeningeal metastases cause

    • Multifocal neurologic deficits from infiltration of nerve roots

    • Direct invasion of the brain or spinal cord

    • Obstructive or communicating hydrocephalus


  • Laboratory and radiology studies are the same as for primary neoplasms

  • Lumbar puncture is needed only if carcinomatous meningitis is suspected

    • Elevated cerebrospinal fluid pressure, pleocytosis, increased protein levels, and decreased glucose concentration are seen

    • Malignant cells may be found on cytology

  • In leptomeningeal metastases, CT scans show contrast enhancement in the basal cisterns or hydrocephalus without any evidence of mass lesions

    • Gadolinium-enhanced MRI often shows leptomeningeal involvement

    • Myelography may show deposits on multiple nerve roots


  • A single cerebral metastasis may be irradiated, sometimes following surgical excision

  • Leptomeningeal metastases receive irradiation and intrathecal methotrexate

    • Prognosis is poor, with an approximately 10% survival at 1 year

    • Palliative care

  • For multiple cerebral metastases or widespread systemic disease, the prognosis is poor

    • Stereotactic radiosurgery, whole-brain radiotherapy, or both, sometimes helps

    • Memantine

      • Dosage: 5 mg orally once daily titrated up by 5-mg daily increments every week to 10 mg orally twice daily

      • In a randomized trial, memantine use prior to and during whole-brain radiotherapy reduced its cognitive toxicity and is therefore recommended

      • This effect can be augmented through intensity modulated radiation therapy with hippocampal avoidance

    • Otherwise, palliative care

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